Provider Demographics
NPI:1528481090
Name:FAIRFIELD COUNTY HEALTH & WELLNESS SERVICES, LLC
Entity type:Organization
Organization Name:FAIRFIELD COUNTY HEALTH & WELLNESS SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TASNEEM
Authorized Official - Middle Name:AHMAD
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-980-9969
Mailing Address - Street 1:325 REEF RD
Mailing Address - Street 2:SUITE # 109
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6537
Mailing Address - Country:US
Mailing Address - Phone:203-955-1822
Mailing Address - Fax:203-955-1823
Practice Address - Street 1:325 REEF RD
Practice Address - Street 2:SUITE # 109
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6537
Practice Address - Country:US
Practice Address - Phone:203-955-1822
Practice Address - Fax:203-955-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0340052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001340059Medicaid
CT001340059Medicaid
CT260003701Medicare PIN